I am a family physician practicing in Toronto, Ontario. I will be implementing an Electronic Medical Record in my practice, starting in March 2006. This blog is a diary of what happened.

Sunday, September 27, 2009

Open Access

We are continuing to implement new things in my office. Here you see an initiative to decrease the number of days that patients have to wait until they get an appointment. We count the "Third Next Available" appointment every Tuesday, and average it for each month. By Third Next Available, I mean that we look at my schedule, and see when the third next open slot is. This is the best way of measuring access to the physician. We went from 23 days to 11 days to 5 days, and last week, we had our first zero: you called that day, you got an appointment that day.

My practice Team is part of QIIP, the Quality Improvement and Innovation Partnership. We are using multiple Plan-Do-Study-Act cycles to change the way we work. It has been hard; after all, routine is comfortable and change is not. However, we are making progress on many fronts.

Part of what you are seeing up there is the result of multiple changes to improve efficiency; we are now trying to do everything when the patient comes in. If you are in for a cold, and the EMR shows that you are overdue for a foot exam for your diabetes, there is an alert in the chart and you get offered a foot exam. If you come in for a rash, and you are due for a Blood pressure check, you also get a blood pressure check. We use the phone a lot; my RN checks in by phone to follow up with patients who are depressed--we use the EMR for messaging about this. We distribute tasks: our Team Clinical Pharmacist now sees several of my diabetics for their routine follow-ups, and monitors all their parameters. I am always on site and available when she is seeing them, but it gives me the time to deal with more complicated problems. My Team is testing a much more complex EMR-based flowsheet (the Chronic Disease Management flowsheet) that incorporates templates that are linked to the CDM flowsheet, along with automatic time-based alerts--and other people in our Family Health Team are interested in doing this as well. In my practice, we have agreed on common ways for all of us to enter data so that it can be extracted to monitor our quality.

I don't just want to cut waiting times for our patients, I also want to maintain or even improve our quality. However, if there is no access there is no quality, so you have to work on both at the same time. I often hear about the effect of EMR on efficiency, and I think what people mean when they talk about this is how fast charting for encounters is, or how fast you can access information when seeing a patient, or how long a consultation takes. I think there is another dimension to efficiency, and that is how well the EMR helps you manage your practice as a whole, and how well it helps you function as a team. If these things improve, then you can see your patients sooner--efficiency gains translated as improved patient access.

Interestingly, the move to the new office has not translated (so far) into a significant decrease in the number of patients I look after. My current roster is 1296, down from 1306. What I have to decide now is whether to open my practice up to new patients again; if I do that without planning, then I think access will worsen and waiting times to see me will increase. My staff are tracking Demand; this is how many appointments are generated each day, whether because I ask the patient to book a follow up (internal demand), or because the patient calls to make an appointment (external demand). We also recently measured how many appointments I have available, by counting how many days I am in the office and how many patients I see each day; this is Supply. Having all this data will help my Team to decide what to do in terms of opening up the practice to new patients. Clearly, if we become more efficient, then we increase Supply; the EMR is an important factor there.

My Team has decided to go to Open Access in January. Several other Teams participating in QIIP have already make the leap, and we have used materials developed in Dr Peterkin's practice (Mapleton Family Health Team) to begin to let our patients know about the change. Open Access means reducing wait times: you call and you get an appointment same day or next clinic day. I have posted initial information about Open Access in this practice here, and Dr Peterkin's poster is now on the Community bulletin board in my waiting room with a note that we will be starting a similar initiative on January 11th 2010.

2 comments:

I had great success implementing Open Access in our FM clinic in 2002. I found (and the research supports this)that the quality of the care we deliver improved because of timely accessibility to us, because we are able to do more with each visit, and because it links our patients to their provider much more effectively. It is an innovation which improves face to face time with our patients, which is why we are here, after all. Our staff and patients love it. I felt the level of anxiety in the practice drop precipitously with the change. The patients are now confident in their ability to see me, and my staff no longer has to turn someone away.

I am interested in your comments on process whereby you say you are engaged in multiple PDSA rapid cycle studies on your workflow. Would love to hear more details on what you are changing. I am a big believer in framing your processes to see how you can improve them.

Thanks for your comments on Open Access, I have heard similar things from other colleagues.

We are changing many things here, using multiple PDSA cycles, http://www.ohqc.ca/en/change.phpWe also use process mapping during our team meetings to try to figure out bottlenecks etc.

A good way to see what we are doing is to read earlier posts; I put things there as they happen.

Here is an example of several cycles:PDSA cycle-1 Mailed Lab reqs to patients one week prior to their physicals, they do the lab test ahead, and have their lab results at their physicals to review. However, the mail is taking too long, and patients are not getting their req in time for their physicals. PDSA cycle-2. Tried to mail lab reqs 2weeks prior, still no enough time? Try one month prior their physicals. Also plan to put date of their physicals on the letter, serve as a reminder.PDSA cycle-3: Expand mailings to another MD in practicePDSA cycle-4: Add preventive questionnaire to req mailing.